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14 APPLICATION SAN .TOAQUII COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIIVISION 445 N SAN JOAQUIN, PHONE (209)468-3420 1 P O BOA 2009, STOCKTON; CA 95201 is PERAd I T E%P I RES 1 YEAR FROM DATE -ISSUED (Complete in Triplicate) Appltcation is hereby rade to Saga Joaquin County for a permit to construct and/or install the work herein described. This application is made in coawlianee with San Joaquin County Ordinance No. 549'1and 1862 and the Rules and Regulations of San Joaquin County Public Health Servieea..j �r^7 Job Address but t �`�� -` City St ckton Lot Size/Acreage 2 Acrps I! Owner's Name Catellus Demo. Cor p Address 201_Mlssiooj, _i],00r _ Phone Sart Francisco, CA ' Contractor ERM __ Address C'_,^C License No. 630406 Phone 0510)256-646 TYPE OF WELL/PUMP' NEW WELL 00 WELL REPLACEMENT C-1 DESTRUCTION 0 Out of Service Well Cl _ PUMP INSTALLATION 0 SYSTEM REPAIR 0. OTHER I'ff Monitoring Well [7 DISTANCE TO NEAREST: SEPTIC TANK' SEWER LINES DISPOSAL FLO. PROP. LINE_ 6 FOUNDATION AGRICULTURE WELL - OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS I (71 Industrial Cl Open Bottorff 0 Manteca Dia. of Well Excavation Die, of Well Casing 4 inch f 1 Domestic/Private S) Gravel Pack 0 Tracy Type of Casing_ -C _ Specifications I'l Public 1-1 Other FI Delta Depth of Grout Seal Type of Grout I i Irrigation --'.Approx. Depth I I Eastern Surface Seal Installed by I Repair Work Done 0 Type of Pump H.P. S1A 1.State Work Done Well Destruction 0 Well Diameter L 4 in yf Sealing Material 6 Depth Concrete 24 inch x Air Sparging Depth • If .�-t� Filler Material i Depth f TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION i I DESTRUCTION I I (No septic system permitted if public sewer is Not Applicable available within 200 feet.) Installation will serve: Residence W_ Commercial X Othar Number of living units: Number of bedrooms_ ° Character of soil to a depth of 3 lees: Water table depth SEPTIC TANK D Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. 0 'Method of Disposal Distance to nearest Well Foundation Property Line . 1 LEACHING LINE Cl No. Ilr Length of lines Total length/size Flt-TER BED CI Distance to neatest: Well Foundation Property Line Not Applicable SEEPAGE PITS I I Depth Sire Number, i •. SUMPS LI Distance to nearest: Well Foundation 4- Property Lina DISPOSAL PONDS 0--Not-Appicablp. I1 I hereby comily that I have prepared this application and that the work will be done in accordance with San Joaquin county ordinances, state laws, and rules and regulations of the San Joaquin County Iil Home owner or licensed agent's signature certifies the following: "I certify that in the performance of the work for which this permit is issued, I shell not j emplov any person in such manner as to become subject to workmen's compensation taws of California." Contractor's hiring or sub-contracting signature certifies the following: "I ce ify that in the performance of the work for which this permit is issued, I sheN employ persons subject to workmen's compensa- tion laws of eliforrUe." 1t The applies utt eaN f r I requir d Irtt;I lions. Cbmplets drawing on r arse std Signed X Title: r�^` v kt� Q� Date: I FOR DEPARTMENT USE ONLY Application Accepted by pate Area Pit or Grout Inspection by Date Final Inspection by Date Additional Comments: c� 4 � naP App}scant - Return all copies to: San Joaquin County Public }Iealth Services G�c.7lir-pNyt` 'Fy �. Environmental Health Permit/Services r 445 N San Joaquin, P O Box 2009, Stkn, CA 95201 1�1rect CKu FEE INFO AMOUNT DUE I AMOUNT REMITTED CASH RECEIVED 9y DATE PEnma'NO. � e i i FH 13-24 IREV.1in5) '"1 !t/LS M .t • �`•�•` C • V+ � ''} FN 14.2e I� IS